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BMJ Quality & Safety Online First, published on 21 July 2015 as 10.1136/bmjqs-2015-004021
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Correspondence to Jochen
Bergs, Faculty of Business
Economics, Hasselt University,
3500 Hasselt, Belgium;
jochen.bergs@uhasselt.be
Received 30 January 2015
Revised 24 June 2015
Accepted 4 July 2015
To cite: Bergs J,
Lambrechts F, Simons P, et al.
BMJ Qual Saf Published
Online First: [ please include
Day Month Year]
doi:10.1136/bmjqs-2015-
004021
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
Barriers and facilitators related to
the implementation of surgical
safety checklists: a systematic
review of the qualitative evidence
Jochen Bergs,1 Frank Lambrechts,1 Pascale Simons,1 Annemie Vlayen,2
Wim Marneffe,1 Johan Hellings,2,3 Irina Cleemput,4 Dominique Vandijck2,5,6
ABSTRACT
Objective The objective of this review is to
obtain a better understanding of the user-related
barriers against, and facilitators for, the
implementation of surgical safety checklists.
Methods We searched MEDLINE for articles
describing stakeholders’ perspectives regarding,
and experiences with, the implementation of
surgical safety checklists. The quality of the
papers was assessed by means of the Qualitative
Assessment and Review Instrument. Thematic
synthesis was used to integrate the emergent
descriptive themes into overall analytical themes.
Results The synthesis of 18 qualitative studies
indicated that implementation requires change in
the workflow of healthcare professionals as well
as in their perception of the checklist and the
perception of patient safety in general. The
factors impeding or advancing the required
change concentrated around the checklist, the
implementation process and the local context.
We found that the required safety checks disrupt
operating theatre staffs’ routines. Furthermore,
conflicting priorities and different perspectives
and motives of stakeholders complicate checklist
implementation. When approaching the checklist
as a simple technical intervention, the
expectation of cooperation between surgeons,
anaesthetists and nurses is often not addressed,
reducing the checklist to a tick-off exercise.
Conclusions The complex reality in which the
checklist needs to be implemented requires an
approach that includes more than eliminating
barriers and supporting facilitating factors.
Implementation leaders must facilitate team
learning to foster the mutual understanding of
perspectives and motivations, and the realignment
of routines. This paper provides a pragmatic
overview of the user-related barriers and facilitators
upon which theories, hypothesising potential
change strategies and interactions, can be
developed and tested empirically.
Bergs J, et al. BMJ Qual Saf 2015;0:1–11. doi:10.1136/bmjqs-2015-004021
SYSTEMATIC REVIEW
INTRODUCTION
Surgical safety checklists are intended to
ensure consistency in patient perioperative
safety and to introduce or maintain
a culture that values achieving it.1 The use
of these checklists is associated with
increased patient safety awareness,
improved communication, reduction of
surgical claims and reduction in the
number of postoperative complications
including mortality.2–10 It cannot, however,
be assumed that the mere application of the
checklist will automatically lead to
improved safety.11–13 Reported compliance
with checklist items is assumed to be corre-
lated with the impact of surgical safety
checklists.10 14 Consequently, the clinical
effectiveness of the checklist will vary with
the implementation success.15 16
The implementation of new guidelines
and safety interventions has been shown
to be difficult in various healthcare sectors,
which highlights the importance of the
implementation process.17–19 Several
studies have reported high levels of partici-
pation and checklist completion (ranging
from 12% to 100%).20 However, the
implementation is more than merely
‘checking the box’. A discrepancy between
ticking off checklist items and the perform-
ance of the actions results in poor fidelity
as regards the checklist’s intentions.21–29
The implementation of a surgical safety
checklist is a complex social intervention.
Factors influencing the dissemination and
uptake of evidence-based interventions or
technological innovation may, therefore,
not apply. In order to increase the under-
standing of the user-related barriers to, and
facilitators of, the implementation of surgi-
cal safety checklists, we conducted a sys-
tematic review of the qualitative literature.
1
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Systematic review
METHODS
Design
A synthesis of the qualitative evidence synthesis was
formulated by means of thematic synthesis.30 The
strength of this methodology is its potential to enable
conclusions to be drawn on the basis of common
elements of otherwise heterogeneous studies.
Conclusions drawn from thematic analysis fulfil an
important research aim of qualitative research by gen-
erating hypotheses for which traditional systematic
reviews are poorly suited.30
Search strategy
The search was performed in MEDLINE (from incep-
tion to March 2015) using the following query:
(“Surgical Procedures, Operative”[Mesh] OR “surgi-
cal” OR “surgery” OR “operative)” AND
(“checklist”[MeSH] OR “checklist” OR “time-out)”
AND (“fidelity” OR “implementation” OR “adher-
ence” OR “compliance” OR “barriers” OR “facilita-
tors” OR “incentives”). Broad search terms were
applied without date restrictions in order to make the
search strategy as sensitive as possible. Methodological
filters for study design were not used because they
reduce the sensitivity of searches.31 32 The reference
lists of all of the papers were scrutinised, and a cited
reference search was made in the Web of Science for
additional papers on the subject.
Inclusion criteria
Qualitative studies that explored the perspectives and
experiences of stakeholders with the implementation
of surgical safety checklists were included. These sta-
keholders were nurses, surgeons, anaesthesiologists,
residents, implementation leaders, administrators and
any others directly involved in, or affected by, the
implementation. Following the guidance of the
Cochrane Qualitative Research Methods Group,
which considers critical appraisal to be a technical and
pragmatic exercise, we restricted the type of qualita-
tive studies included in this review.33 Only empirical
studies with a description of the sampling strategy, the
data collection procedures and the type of data ana-
lysis were included. These empirical studies had to
report the methodology chosen and the methods or
research techniques opted for since this facilitates the
systematic use of critical appraisal as well as a more
pragmatic appraisal process. Therefore, descriptive
papers, editorials and opinion papers that were not
based on actual experiences related to the implemen-
tation of surgical safety checklists were excluded. No
language or country restrictions were applied.
Quality assessment
The primary goal of our quality assessment was to
highlight the quality of the published literature on the
subject. The full texts of the included articles were
reviewed by two independent authors ( JB and PS)
2 Bergs J, et al. BMJ Qual Saf 2015;0:1–11. doi:10.1136/bmjqs-2015-004021
using the Qualitative Assessment and Review
Instrument (QARI).34 The 10 QARI criteria do not
relate to validity or bias in the process-orientated
methods as regards the reviews of effects, their
purpose being to establish the nature and appropriate-
ness, the methodological approach, the specific
methods and the representation of the voices or
meanings of the study participants.35 However, given
that there is no accepted method for excluding quali-
tative studies from the syntheses on the basis of their
quality, we did not exclude studies based on the QARI
scoring.36 37
Extracting data from studies
A data extraction form was developed cataloguing the
author, year of publication, journal, method of data
collection, phenomena of interest, study setting,
country of study, data analysis and main conclusions.
In syntheses of qualitative research, the ‘informants’
are the authors of the individual studies rather than
the participants in these studies. Therefore, the
authors’ interpretations—presented, for example, by
themes and categories—constitute our data. While the
authors’ interpretations were collected primarily from
the results sections, data found in the discussion
sections were also extracted when relevant and well
supported by data.
Thematic synthesis
Thomas and Harden described thematic synthesis as
“a tried and tested method that preserves an explicit
and transparent link between the conclusions and text
of the primary studies; as such it preserves principles
that have traditionally been important to systematic
reviewing”.30 Thematic analysis has three stages: (a)
line-by-line coding of the findings of primary studies
to extract the key concepts, (b) organisation of these
key concepts into related areas to construct ‘descrip-
tive’ themes that formed the backbone of the structure
of the analysis and (c) development of ‘analytical’
themes based on the synthesis of the experiences and
recommendations of authors of the original articles.
While the development of descriptive themes remains
close to the primary studies, the analytical themes rep-
resent a stage of interpretation in which the reviewers
go beyond the primary studies and generate new inter-
pretive constructs, explanations or hypotheses.
QSR International’s NVivo 10 software was used to
organise the codes into hierarchical structures.38 The
text of each included study (results and discussion
section) was imported into the software verbatim.
One of us ( JB) developed a set of descriptive codes
inductively by coding each line of the text of all of
the included studies. We looked for similarities and
differences between the codes in order to start group-
ing them into a hierarchical tree structure, and new
codes were created to catalogue the meaning of
groups of initial codes. This process resulted in a tree
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structure with several layers in order to organise the
descriptive themes. The groupings were then further
refined by discussion and rechecking of the original
studies ( JB, FL and PS). Successive drafts of a narra-
tive that described the themes seen in the findings
were then discussed by the wider study group ( JB, FL,
PS, AV and DV) and further refined. All of the stages
of the process were checked by various experts (an
organisational psychologist, safety culture experts and
patient safety experts) to ensure accuracy and control
of bias in the analysis.
RESULTS
The search strategy yielded 535 papers. Screening for
eligible and inconclusive abstracts reduced this list
to 45 papers. After full-text review, 27 studies21 22
27–29 39–60
were excluded from the final analysis
(see online supplementary appendix 1 for further
explanation). We included 18 studies involving >700
healthcare professionals (see figure 1).25 61–77 The
studies involved 18 different countries. The data in
these studies had been collected using interviews,
focus groups, observations and open-ended surveys.
A detailed overview of the study characteristics is
provided in online supplementary appendix 2.
Quality assessment
Overall, the selected studies scored well on the QARI
(see online supplementary appendix 3 for an overview
of QARI scoring). Nevertheless, only 4 of the 18
papers stated the cultural and/or theoretical location
of the researcher, so it was difficult to appraise his/her
Figure 1 PRISMA diagram.
Bergs J, et al. BMJ Qual Saf 2015;0:1–11. doi:10.1136/bmjqs-2015-004021
Systematic review
potential influence on the study findings and vice
versa. Adequate representation of the participants,
and their opinions, was not provided in five studies,
and the congruity between the stated philosophical
perspective and the research methodology was often
difficult to evaluate. No additional exclusions were
made after the technical appraisal.
Synthesis findings
The thematic analysis of the primary articles revealed
five main themes with respective subthemes. Two of
these main themes—staffs’ perception of the checklist
and patient safety, and workflow adjustments—repre-
sent user-related changes required to conduct the
checklist as intended (dimension one). The other
three main themes—checklist, implementation process
and local context—constitute factors affecting the
user-related changes (dimension two). Figure 2 shows
our data structure. It provides a graphical representa-
tion of how we progressed from subthemes (the result
of grouping key concepts from the primary studies) to
main themes describing the two dimensions.
User-related changes required to conduct the checklist as
intended
In order to implement the checklist and assure it is
used as intended, changes on the user level (ie,
doctors and nurses) are needed. In what follows, we
describe the main themes and subthemes related to
this first dimension. Illustrative quotations for each of
the themes are provided in table 1.
3
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Systematic review
Figure 2 Data structure.
Staffs’ perception of the checklist and patient safety
The perception of the staff of the checklist and its
items, and the perception of patient safety in general,
determines the individual willingness to use the check-
list. Healthcare providers expressed concerns about
legal implications, which hampered their willingness
to use the checklist. Participants, especially nurses,
expressed concerns about patient perception, which
led to the omission of items they perceived as causing
stress in patients (eg, expected blood loss) or perform-
ing the checks without verifying out loud. Most of the
studies reported concerns about time consumption
and efficiency. Participants felt, or presumed, that
checklist execution consumed too much time and
thereby hampered operating theatre efficiency. The
perceived importance of the checklist items varied
across professions and individuals, which led to
varying usage and support among surgeons, anaesthe-
siologists and nurses. The perceived importance is
strongly related to understanding the intentions and
aims of the checklist. In addition, risk perception
plays an important role in the conviction that risks
assumed by the checklist exist in the immediate work
environment. Finally, scepticism regarding the evidence
base was expressed. Surgeons and anaesthetists, in par-
ticular, believed that the existing evidence was incon-
clusive and did not support general implementation of
surgical safety checklists.
Workflow adjustments
Implementation of the checklist requires modification
of operating theatre staffs’ workflow. Proper execution
4 Bergs J, et al. BMJ Qual Saf 2015;0:1–11. doi:10.1136/bmjqs-2015-004021
of the safety checks introduced by the checklist
involves changes in the workflow of the operating
theatre staff, which was often experienced as an
increased workload. Besides individual workflow
adjustments, alignment between the workflows of sur-
geons, anaesthesiologists and nurses is needed in
order to execute the brief stops (ie, sign in, time out
and sign out) required to complete the checklist.
Aligning the workflow of team members is difficult to
achieve. In addition, the checklist sometimes entails
the repetition by nurses or doctors of one or more
safety checks—as some are already included in exist-
ing procedures—the redundant registration thus creat-
ing an administrative burden. As a result, doctors and
nurses might experience the checklist as an additional,
often unnecessary, task.
Factors affecting the user-related changes
Several factors act as a barrier or facilitator to the
user-related changes required to precede checklist
usage. In what follows, we describe the main themes
and subthemes related to this second dimension.
Illustrative quotations for each of the themes are pro-
vided in table 2.
The checklist
A first theme emerged around design problems influ-
encing staff perception and workflow. Many health-
care providers found the content somehow irrelevant
to their setting or suggested rewording certain items
to create a better fit with actual usage. Layout and
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Systematic review

Table 1 Themes describing user-related changes required conducting the checklist as intended with exemplary citations from the study
findings
Main theme Subtheme Exemplary citations from the study findings
Staffs’ perception of the Concerns about legal Nurses were therefore concerned about the legal implications of signing the checklist
checklist and patient safety implications as they might be held accountable for errors.68
Concerns about patient For example, some stated that patients often did not understand why they had to
perception confirm their ID/procedure, etc., so many times during their surgical pathway, and
others felt that specific questions around blood loss and difficult airway (part of the
sign-in checks) would anxiety provoking for certain patients (this was a particular
concern if the patient was undergoing a local anaesthetic procedure and therefore
witnessed all of the checks).76
Concerns about time …respondents had significant concern about its perceived effect on OR efficiency.70
consumption and efficiency
Perceived importance Confirming the team members by name and role was the most missed check. The
explanation given for this was that a lack of staff turnover and degree of familiarity
with each other made this check appear less important.73
Scepticism regarding the Scepticism regarding the evidence base: The evidence base behind the checklist is
evidence base weak and/or not applicable to the current context.76
Workflow adjustments Individual workflow Two participants expressed concern about the interruption in workflow that was
adjustments sometimes required to complete the checklist discussion.61
Aligning the workflow of team These asynchronous workflows impacted on a healthcare professional’s ability to halt
members their work and collaboratively meet to communicate at a time-out procedure: Time out
was about to commence and the nurse initiating it asked the anaesthetist “Are you
joining us?” The anaesthetist replies, “No, we have things to do”.
[Obs_circnurs_125]25

form factor issues (eg, inconvenient format or
complex computer applications) were also expressed.
Second, respondents found that the execution process
did not merge with existing processes. This created
redundant safety checks and administration or even
conflicting workflows. Linked to beliefs and preju-
dices, as previously mentioned, professionals need to
experience psychological ownership, meaning that
they must have the feeling that the intervention is
created, or at least tailored, to their needs. This sense
of ownership seems crucial in convincing doctors to
use the checklist. Even though the checklist is
supported by evidence and is endorsed by leading
organisations (eg, professional associations),

Table 2 Themes describing the factors affecting the user-related changes with exemplary citations from the study findings
Main theme Subtheme Exemplary citations from the study findings
The checklist Checklist content The binary (yes/no) response system was ambiguous and confusing.68
Execution process did not merge with … duplication with existing processes that already covered several of the items in the
existing processes surgical checklist.68
Psychological ownership … they [surgeons] did not necessarily agree with it, albeit this protocol was endorsed by
the College of Surgeons.62
staff should have been involved in adapting and implementing the SSC as a means of
fostering ownership.74
The implementation Education and training Many participants said that they did not receive information or training on how to use
process the SSC…. 74
Unclear guidelines Many participants said that staff were uncertain about how to use the SSC and who was
responsible for leading it.74
Surgeons commitment Physician’s support and motivation were crucial for implementing the checklist.63
The local context Executive leadership … lack of clarity and agreement with protocol specifics, and inadequate executive
leadership primarily resulted in reduced ownership and acceptance of the protocol by
physicians.68
Hospital leadership was not seen as involved in either promoting or actively
implementing the SSC.74
Organisational culture The same proportion of staff held the perception that the culture within their hospital
was that of a general resistance to the introduction of change, whatever form it takes,
particularly from more senior members of staff.76
Communication and teamwork We often talk about being one team, but it is in itself three teams. The surgeons don’t
see themselves as part of the team; they see the others forming the team, but they invite
in so to speak.62

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Systematic review
individuals may have a different opinion on its useful-
ness and importance. Some parts or items of the
checklist are perceived as relevant only to specific pro-
fessionals, which diluted the sense of shared
responsibility.
The implementation process
The implementation process refers to the joint activity
of implementing the checklist by actors who, in rela-
tion to checklist implementation, engage in particular
ways of relating over time.78 This process must create
a clear transition period supporting the acquisition of
the new workflow. A large part of the implementation
effort entails education and training. Participants from
the original studies found explaining why the checklist
is necessary, providing clear communication on organ-
isational intentions, and addressing the concerns
expressed by staff to be of vital importance for creat-
ing support and willingness prior to the actual imple-
mentation. In addition, participants found it
important to show them how they must use the check-
list. Healthcare providers found that unclear guide-
lines hampered checklist execution. Therefore, the
introduction needs to be supported with clear guide-
lines and training on how, when and who will execute
the checklist. During the implementation process, the
commitment of all of the professionals is required to
sustain checklist usage. Nurses found surgeon commit-
ment to be imperative. Given the hierarchical context
within the operating theatre, senior surgeons’ leader-
ship is of undeniable importance.
The local context
The local context refers to the local historical-
relational context of checklist implementation that is
always partly created in the joint activity that the
actors engage in.78 Participants expressed that, in add-
ition to general leadership, executive leadership is
needed to communicate the importance of the check-
list and patient safety in general. Executive leadership
needs to be exercised in order to create a context in
which doctors and nurses feel supported. Across
studies, respondents saw the organisational culture as
a major barrier but also as a potential facilitating
element. Both the hospital-wide and the immediate
organisational culture play a mediating role. Although
checklist usage is expected to change the safety
culture, there is a very complex relationship between
the checklist, the procedures, the context, the culture
and the behavioural changes.72 With the deepening of
the culture, respondents found that communication
and teamwork issues hamper checklist execution.
These issues often stem from a hierarchical team
culture that obstructs the open culture and communi-
cation required to execute the checklist correctly. The
social interaction between team members has a great
impact on nurses’ decision to participate in checklist
usage. They seem to adjust their team involvement
6 Bergs J, et al. BMJ Qual Saf 2015;0:1–11. doi:10.1136/bmjqs-2015-004021
according to the practical, social and professional con-
ditions in their work environment.
Analytical themes
Up to this point, we have produced a synthesis that
kept very close to the original findings of the studies.
‘Going beyond’ the content of the original studies has
been identified by some as the defining characteristic
of synthesis.30 With the development of analytical
themes, we ‘went beyond’ the findings of the primary
studies and generated additional concepts, under-
standings or hypotheses.
Disrupted routines and conflicting priorities
The introduction of a checklist in the operating theatre
involves doctors and nurses changing existing rou-
tines.25 Workflows on the individual, professional or
team level have to be altered and aligned in order to
create a brief moment of reflection to review the safety
checks collectively.25 61–63 74 76 77 The workflow intro-
duced by the checklist often collides with existing rou-
tines.61 63 This creates conflicts as existing workflows
are established in function of different priorities (eg,
efficiency or productivity).61 62 66 68 77 Hence, the pri-
ority of patient safety, introduced by the checklist, has
to compete with the already existing clinical and organ-
isational priorities. Conflicts between priorities compel
doctors and nurses to weigh using the checklist against
other priorities. When a conflict in priorities emerges,
the perceptions of operating theatre staff regarding
patient safety drive their ultimate decision about
whether or not to use the checklist.66
Different perspectives and motives
The motivation for implementing a surgical safety
checklist differs between healthcare providers and
hospital management.62 70 75 77 The use of a surgical
safety checklist is often part of hospital-accreditation
requirements or other quality-improving programmes.
Management feels, with the perspective of obtaining
accreditation, that it is necessary to apply the checklist
very strictly. Healthcare providers, however, feel that
some of the checklist items have little or no relevance
in their specific setting. Without clear communication
about the motives of hospital management, perspec-
tives drift apart and resistance towards the checklist
develops. The perspective and motivation of the
doctors may also differ from those of the nurses.
Because of organisational requirements, nurses feel it
necessary to use the checklist while doctors may not
always concur with these requirements.66
The checklist is implemented as a simple technical intervention
The implementation of checklists is more than requiring
that box be checked off: it is a complex social interven-
tion with an expectation of interaction and cooperation
between surgeons, anaesthetists and nurses.63 66 75
However, this important aspect is often poorly
addressed during implementation. Implementation
teams should, therefore, promote and support inter-
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professional communication when introducing the
checklist. If not, the checklist will be used as a tick-off
exercise.79
DISCUSSION
This systematic review comprehensively investigates
user barriers and facilitators to the implementation of
surgical safety checklists. Although the themes have
been presented separately, implementation problems
are multifactorial, highly interdependent and affected
by considerable clinical complexity. Many themes
were common to papers regardless of interstudy
differences in geographical or clinical setting.
It was found that the implementation of a surgical
safety checklist requires change in perception of the
operating theatre staff regarding the checklist and its
items, and the perception of patient safety in general.
In addition, doctors and nurses need to adjust their
workflows. These changes are impeded or advanced
by characteristics of the checklist, the implementation
process and the local context.
Based on the experience of high-reliability organisa-
tions, characteristics of the checklist (eg, length,
layout and design, and content) are important.44 The
content of the checklist needs to be supported by sci-
entific evidence and written in clear, understandable
words preferably embedded within existing processes.
The checklist must precisely mirror the intended oper-
ation without creating ambiguity or confusion. The
checklist and its items must be relevant to the applied
setting. Exporting a checklist to situations in which it
was not meant to be used may impede further check-
list implementation.63 Obstacles stemming from the
checklist apply not only to the content but also to psy-
chological ownership. Doctors and nurses need to feel
as though the checklist has become a part or an exten-
sion of their selves. In other words, they have to feel
that it is ‘mine’ or ‘ours’.80 Even better is collective
psychological ownership, with the entire operating
theatre staff feeling that the checklist is part of them
and their work.81
The implementation process itself can act as a
barrier and so create aversion. As with any new pro-
cedure or guideline implementation, the checklist
creates uncertainty and questions. Lack of consensus
guidelines will lead to personal interpretations and
enhance confusion. Therefore, the introduction needs
to be supported by clear guidelines on how, when and
who will execute the checklist. These guidelines need
to be formalised in a written procedure, and the exe-
cution of the checklist also needs to be demonstrated.
Small-scale tests can familiarise doctors and nurses
with the checklist and experiment with workflow
adjustments. Reactions to these tests can be used to
alter or clarify checklist guidelines and procedures.
Surgeons, who play the central role during the pro-
cedure, are often seen as leaders in the operating
theatre. Research on the broader context of patient
Bergs J, et al. BMJ Qual Saf 2015;0:1–11. doi:10.1136/bmjqs-2015-004021
Systematic review
safety has shown that senior staff may not always be
the best source of patient safety knowledge and
skills.82 This suggests that surgeons not only need to
be supported but also to be educated. A promising
approach to deal with the difficulties associated with
changing routines can be found in team learning.83
Successful implementers used enrolment to motivate
the team, designed preparatory practice sessions and
early trials to create psychological safety (ie, a shared
belief that the team is safe for interpersonal risk
taking) and encourage new behaviours, and thus
promote shared meaning and process improvement
through reflective practices.83 84
The local context in which the checklist has to be
implemented is important. The organisational culture
—that is, a social-organisational phenomena, in terms
of behaviour or attitudes, that emerges from a
common way of sense making, based on shared
values, beliefs, assumptions and norms85—influences
the behaviour and perception of doctors and nurses.
People often view themselves as members of a com-
munity of practice with established norms and pro-
cesses that can change only when the entire group
changes. For example, a new workflow practice or
technology standard may be difficult to adopt unless
the entire group agrees at the same time to use the
system. To improve the safety culture in the operating
theatre, interventions should aim at minimising the
hierarchy and empowering nursing staff in addition to
standardising and structuring the practicalities con-
cerning the use of the checklist. Such initiatives need
to be performed by the operating theatre manage-
ment.66 Second, leadership (ie, the process of social
influence in which one person can enlist the aid and
support of others in the accomplishment of a common
task86) from senior staff and the chief surgeon has been
frequently presented as a key to successful implementa-
tion.25 62–64 66 68 69 72 In addition, participants found
executive leadership equally important. It is important
to show that patient safety is regarded as a priority in
the hospital.62 64 66 69 72 Finally, communication and
teamwork have a profound influence on checklist
usage. The existence of a professional hierarchy in
medicine and the differential status accorded to those
in different disciplines hampers teamwork and com-
munication. Profession-derived status is associated
with psychological safety, so it is important to have a
sense of confidence that the team will not embarrass,
reject or punish someone for speaking up when
noticing a real or potential safety problem.
Psychological safety is a key antecedent of speaking up
and learning behaviour in healthcare teams.87 It is sug-
gested that leader inclusiveness moderates the relation-
ship between status and psychological safety.87
We found that the workflow introduced by the
checklist often collides with existing routines.61 63
This creates conflicts as existing workflows are estab-
lished to achieve different priorities (eg, efficiency or
7
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Systematic review
productivity). The effect of disrupted routines has
previously been recognised during the implementation
of new technology in hospitals.83 Conflicts between
priorities compel doctors and nurses to balance using
the checklist against other priorities. When a conflict
in priorities emerges, the perceptions of the operating
theatre staff regarding patient safety drives their ultim-
ate decision whether or not to use the checklist. We
found that stakeholders’ perspectives and motives
towards the checklist often differ. These different
views create tension and aversion. In order for a
checklist to be considered a priority, staff ’s percep-
tions and attitudes regarding it and patient safety in
general must be supportive. Therefore, the safety
checklist will be of little value if disruptive attitudes
and behaviours are not addressed.88 This is in line
with the establishment of a climate of safety (ie,
shared perceptions among the staff concerning the
policies, procedures, practices and kinds of behaviours
that will be rewarded and supported with regard to
safety89 90). This requires that a good safety climate
must be established prior to, and during, implementa-
tion. New routines require adjustment and training.
An important feature of checklists is the combination of
checks ensuring adherence to proven practices (eg,
administration of antibiotics and use of pulse oximeters)
and other non-technical items (eg, team introductions
and confirmation of procedures). The principal purpose
of these non-technical items is to promote specific
aspects of teamwork, communication and situational
awareness.72 However, education and training during
checklist implementation often neglects these non-
technical items. The importance of team learning and
training in order to modify teamwork and communica-
tion has been implemented with positive effects.91
The checklist is in essence a complex social inter-
vention aimed to improve communication and team-
work in a strictly hierarchical context. Even when
initial perceptions and attitudes regarding the checklist
are positive,92 it does not guarantee long-term
improvement.93 The existing hierarchies and the tribal
affiliations of professional groups must be altered in
order to create psychological safety. Each member has
to be allowed to take interpersonal risk by speaking
up if any concern about safety arises without being
afraid of being embarrassed, rejected or punished.87 94
Implementation is much more complex than addres-
sing the barriers and enabling the facilitators found in
this review. Implementation is an ever-changing
process for change in one aspect can generate a reac-
tion in one or several other aspects and thereby create
a wholly new environment. Hence, it is not enough to
have a list of barriers and facilitating factors: we also
need to deal with the interaction between them.
Strengths and limitations of this study
The results of this thematic synthesis should be inter-
preted within certain limitations. First, only one
8 Bergs J, et al. BMJ Qual Saf 2015;0:1–11. doi:10.1136/bmjqs-2015-004021
electronic database (MEDLINE) was consulted. To
mitigate the potential loss of relevant articles, a cited
and citing reference study in Web of Science was con-
ducted. Second, assessing the quality of the included
studies remains controversial in qualitative reviews. The
QARI was selected because it is referred to as the most
coherent instrument for evaluating the validity of quali-
tative research.34 Last, this review specifies a list of
themes that are believed to influence checklist imple-
mentation but does not specify the interactions
between them.
The current research also has some notable
strengths. First, to the best of our knowledge, this is
the first overview of qualitative research on the bar-
riers and facilitating factors regarding the implementa-
tion of checklists. The results of this study present the
barriers and facilitators that play during the imple-
mentation of many patient safety initiatives in health-
care and, therefore, present a valuable learning
opportunity. Second, the use of thematic synthesis
enabled the synthesis of the results of otherwise het-
erogeneous studies.
CONCLUSIONS
Implementation of a checklist requires structural
changes in workflow of the operating theatre staff work-
flow, as well as in their perceptions regarding the check-
list and patient safety in general. The required changes
are impeded or advanced by three main factors: the
checklist, the implementation process and the local
context. However, the complex reality in which the
checklist is implemented requires an approach that
includes more than getting rid of the barriers and sup-
porting facilitating factors. Implementation leaders must
facilitate team learning to foster mutual understanding
of the perspectives and motivation and the adaptation
of existing routines. This paper provides a pragmatic
overview of the constructs upon which theories,
hypothesising potential change strategies and interac-
tions, can be developed and tested empirically.
Author affiliations
1
Faculty of Business Economics, Hasselt University, Hasselt,
Belgium
2
Faculty of Medicine and Life Sciences, Hasselt University,
Hasselt, Belgium
3
Department of Management, General Hospital AZ Delta,
Roeselare, Belgium
4
Belgian Health Care Knowledge Center (KCE), Brussels,
Belgium
5
Faculty of Medicine and Health Sciences, Ghent University,
Ghent, Belgium
6
Department of General Internal Medicine, Ghent University
Hospital, Ghent, Belgium
Contributors Study concept and design: JB and DV. Acquisition
of data: JB, PS and AV. Collection, analysis and interpretation of
data: JB, FL, PS, AV and DV. Draft of the manuscript: JB. All
authors contributed substantially in reviewing the manuscript
and approved the final version.
Funding Limburg Sterk Merk.
Competing interests None declared.
 Downloaded from http://qualitysafety.bmj.com/ on July 26, 2015 - Published by group.bmj.com
Provenance and peer review Not commissioned; externally
peer reviewed.
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Barriers and facilitators related to the

implementation of surgical safety checklists:
a systematic review of the qualitative
evidence
Jochen Bergs, Frank Lambrechts, Pascale Simons, Annemie Vlayen,
Wim Marneffe, Johan Hellings, Irina Cleemput and Dominique Vandijck

BMJ Qual Saf published online July 21, 2015

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